Clinical Review & Education
JAMA Cardiology Clinical Guidelines Synopsis
Assessment and Treatment of Syncope Win-Kuang Shen, MD; Robert S. Sheldon, MD, PhD
GUIDELINE TITLE 2017 American College of Cardiology (ACC)/American Heart Association (AHA)/Heart Rhythm Society (HRS) Guideline for the Assessment and Management of Patients with Syncope
FUNDING SOURCES ACC/AHA/HRS TARGET POPULATION Patients with syncope
MAJOR RECOMMENDATIONS DEVELOPERS ACC/AHA/HRS RELEASE DATES March 9, 2017 (online); June 2017 (print)
This guideline covers the assessment and treatment of patients with syncope. The broader categories of transient loss of consciousness and postural tachycardia syndrome were not covered.
PRIOR VERSION None
Summary of the Clinical Problem Syncope is a common clinical problem that can affect a wide range of patient populations. Like fever, it is a symptom with many causes, and its risk stratification, diagnosis, and treatment are frequently difficult. The purpose of the American College of Cardiology (ACC)/ American Heart Association (AHA)/Heart Rhythm Society (HRS) Guideline1 was to provide contemporary, accessible, succinct, and practical guidance on treating adult and pediatric patients with suspected syncope.
Characteristics of the Guideline Source This guideline was developed by the ACC/AHA/HRS.1 The writing committee was composed of clinicians with expertise in caring for patients with syncope. They included representatives from the ACC, AHA, HRS, American Academy of Neurology, American College of Emergency Physicians, and Society for Academic Emergency Medicine. It used systematic review methods derived from the ACC/ AHA Guidelines classes of recommendations and levels of evidence. A key contribution was to compile, refine, and develop simple bedside definitions for syncope syndromes based on earlier reports, including those of the European Society of Cardiology,2 the Gargnano Workshop,3 and the American Autonomic Society.4
better outcomes and quality of life and reduced costs. In the guideline documents, the class of recommendation indicates the strength of the recommendation, encompassing the estimated magnitude and certainty of benefits in proportion to risk. The level of evidence rates the quality of scientific evidence that supports the intervention on the basis of the type, quantity, and consistency of data from clinical trials and other sources. Class of recommendations are determined independently from the level of evidence. Class I recommendations denote that benefits strongly outweigh risks. Class II recommendations are made when benefits moderately outweigh risks. Class III recommendations are made when either there is no benefit or when risks outweigh benefits (harm).1
Discussion Risk Assessment and Initial Management
Risk stratification is key in the initial assessment of syncope (Figure). Several independent factors predict poor outcomes, including being
Figure. Syncope Initial Evaluation Transient loss of consciousness
Evidence Base The ACC/AHA Task Force on Clinical Practice Guidelines review, update, and modify guideline methods based on published standards from organizations, such as the Institute of Medicine, and on internal reevaluation. When developing recommendations, the writing committee uses evidence-based methods that are based on all available data. Literature searches include randomized clinical trials, registries, nonrandomized comparative and descriptive studies, case series, cohort studies, systematic reviews, and expert opinions.1
Suspected syncope
No
Evaluation as clinically indicated
Yes Initial evaluation: history, physical examination, and electrocardiogram (class 1)
Cause of syncope certain
Risk assessment
Cause of syncope uncertain
Benefits and Harms The guidelines are intended to reduce the heterogeneity in the current practice of synecope. They should reduce the harm caused by overinvestigation and underdiagnosis and provide the benefits of jamacardiology.com
Treatment
Further evaluation
Colors correspond to class of recommendation. Adapted from Shen et al.1
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Clinical Review & Education JAMA Cardiology Clinical Guidelines Synopsis
older than 60 years, being male, a lack of a prodrome, experiencing syncope while in a supine position or during exercise, experiencing palpitations preceding syncope, a family history of early sudden death, hypotension, anemia, and an abnormal electrocardiogram result. Patients with serious morbidities should be admitted to a hospital while those with clearly reflex-mediated syncope could be managed as outpatients. Intermediate–risk patients might benefit from investigation protocols in emergency departments. Diagnostic Approach
A meticulous history, physical, and electrocardiogram are key to making a diagnosis. If a diagnosis can be made confidently on these bases, no further testing should be done; if not, neither blanket testing nor a uniform investigational protocol is recommended. Testing should be based on clinical judgment. Tilt testing can be helpful to investigate possible convulsive syncope, pseudosyncope, and suspected but uncertain vasovagal syncope. Brain computed tomography or magnetic resonance imaging, electroencephalogram, and carotid ultrasonography are unhelpful and should not be ordered. Ambulatory electrocardiograms can be helpful and the selected technology should be based on symptom frequency. Investigations of cardiac causes of syncope should follow the relevant guideline-directed management and therapy. Managing syncope in athletes and children should involve professionals with specific relevant expertise.
gal syncope and prolonged spontaneous pauses. This is a rapidly evolving field, and practitioners should restrict use to highly symptomatic patients and possibly seek advice from experts. The management of other cardiac causes of syncope should follow the guideline-directed management and therapy. Orthostatic Hypotension
Orthostatic hypotension frequently causes syncope. Causes such as dehydration and overmedication should be determined, but some patients have autonomic neuropathies. These may be because of serious and occasionally occult conditions, and a referral for a specialized autonomic evaluation can be helpful. Treatment is supportive and involves counterpressure maneuvers, compression stockings, fludrocortisone, midodrine, and other medications. Driving
The aim of assessing a patient’s medical fitness to drive is to balance the risk of causing injury or death to the driver or others with the need for patients to drive to meet the demands of family life and work. There are few data available on this subject, and the writing committee only provided suggestions that were based on expert opinions. These apply to private drivers; commercial driving in the United States is governed by federal law and administered by the Department of Transportation. Health care professionals should know and follow local driving laws and regulations.
Treatment of Vasovagal Syncope
This should be tailored to the individual patient. All patients should be reassured about its benign outcome, encouraged to increase salt and fluid intake where possible, and coached on counterpressure maneuvers. Although the data are weak, they are sufficient to consider using fludrocortisone and midodrine for patients without hypertension or heart failure, β-blockers in patients older than 42 years without asthma or depression, and serotonin-reuptake inhibitors. A formal external systematic review and meta-analysis5 recommended that dual-chamber pacing could be used among highly symptomatic patients older than 40 years with recurrent vasovaARTICLE INFORMATION Author Affiliations: Mayo Clinic, Phoenix, Arizona (Shen); University of Calgary, Calgary, Alberta, Canada (Sheldon). Corresponding Author: Win-Kuang Shen, MD, Mayo Clinic, 5777 E Mayo Blvd, Phoenix, AZ 85054 (
[email protected]). Published Online: June 14, 2017. doi:10.1001/jamacardio.2017.1784 Conflict of Interest Disclosures: Both authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr Shen is the chair of the Syncope Guideline and Dr Sheldon is the vice chair. REFERENCES 1. Shen WK, Sheldon RS, Benditt DG, et al. 2017 ACC/AHA/HRS guideline for the evaluation and
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Areas in Need of Future Study or Ongoing Research Standardized national registries and large databases are needed to understand syncope incidence and prevalence and patient risk, inform driving policies, improve patient outcomes, and improve the delivery of health services. Prospective studies are needed to define clinical outcomes and assess risks from recurrent syncope as well as nonfatal and fatal outcomes. They should gather data on quality of life, work loss, and functional capacity. Mechanistic investigations and randomized clinical trials are needed to improve therapeutic outcomes.
management of patients with syncope: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines, and the Heart Rhythm Society [published online March 9, 2017]. Circ. doi:10.1161 /CIR.0000000000000499. 2. Moya A, Sutton R, Ammirati F, et al; Task Force for the Diagnosis and Management of Syncope; European Society of Cardiology; European Heart Rhythm Association ; Heart Failure Association; Heart Rhythm Society. Guidelines for the diagnosis and management of syncope (version 2009). Eur Heart J. 2009;30(21):2631-2671. 3. Sun BC, Costantino G, Barbic F, et al. Priorities for emergency department syncope research. Ann Emerg Med. 2014;64(6):649-655.e2.
orthostatic hypotension, neurally mediated syncope and the postural tachycardia syndrome. Clin Auton Res. 2011;21(2):69-72. 5. Varosy PD, Chen LY, Miller AL, Noseworthy PA, Slotwiner DJ, Thiruganasambandamoorthy V. Pacing as a treatment for reflex-mediated (vasovagal, situational, or carotid sinus hypersensitivity) syncope: a systematic review for the 2017 ACC/AHA/HRS guideline for the evaluation and management of patients with syncope: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society [published online March 3, 2017]. J Am Coll Cardiol.
4. Freeman R, Wieling W, Axelrod FB, et al. Consensus statement on the definition of
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